Main outcome measures Rates of prescribing and use of procedures and medical devices relative to evidence based guidance.

Results 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued.

Conclusions Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.

Footnotes

The interview schedule for clinicians is on bmj.com

Funding NHS R&D National Co-ordinating Centre for Research Methodology (NCCRM).

Competing interests NC was a member of the NICE Appraisals Committee between 1999 and 2002. KL, PW, DW, and JM work for York Health Economics Consortium, which undertakes work for a range of pharmaceutical companies, the Department of Health, and the NHS and has undertaken a cost-effectiveness study for Guidant, which manufactures implantable cardioverter defibrillators. This study was submitted to NICE as part of the assessment process.

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SheldonTrevor A, CullumNicky, DawsonDiane, LankshearAnnette, LowsonKarin, WattIan et al. What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviewsBMJ 2004; 329 :999